Carer mentoring: A mixed methods investigation of a carer mentoring service

International Journal of Nursing Studies 51 (2014) 359–369

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Carer mentoring: A mixed methods investigation of a carer mentoring service Nan Greenwood *, Ruth Habibi Faculty of Health, Social Care and Education, St George’s University of London and Kingston University, Cranmer Terrace, London SW17 0RE, UK

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 February 2013 Received in revised form 7 June 2013 Accepted 13 June 2013

Background: Worldwide with ageing populations, the numbers of informal carers are likely to increase. Although being a carer is often satisfying, it can be challenging and require support. Volunteer-provided carer mentoring services where carers are supported by volunteer mentors are one such intervention. However, little is known about the impact of mentoring, carers’ experiences or the mechanisms by which these schemes may work. Previous quantitative findings have been inconsistent suggesting a different, mixed methods approach using qualitative and quantitative methods may be valuable. Objectives: Objectives were to explore two main questions: whether mentoring had a significant positive effect on carer mentees in terms of mental health, quality of life and confidence in caring and to explore how carers experience and perceive the process and benefits of mentoring. In addition, the study aimed to suggest possible mechanisms to understand how mentoring may benefit carers. Methods and setting: Mixed methods (quantitative questionnaires and depth interviews) investigated an established mentoring service provided by volunteer mentors. During the study period, 28 carers received mentoring. Of these, 25 carers completed structured questionnaires both before and after mentoring, to determine whether mentoring had an impact on carer wellbeing and confidence in caring. Depth interviews were also undertaken with 11 purposively sampled carers to explore how carers experience and perceive the process and benefits of mentoring. Results: Statistically significant improvements in carer anxiety (p < 0.001), depression (p < 0.001), quality of life (p = 0.02) and confidence in caring (p < 0.05 on all dimensions except one) were found. Depth interviews revealed that carers were very positive about mentoring and highlighted many benefits. Findings suggested emotional support, information provision, problem solving facilitation and gaining new perspectives may be mechanisms by which mentoring achieves positive outcomes. Mentor personal characteristics, experiences and training are possible facilitators of the process. Conclusions: Carer mentoring services can be a valuable form of carer support that falls somewhere between formal and informal support. Adopting mixed methods permitted greater understanding of how mentoring may benefit carers and has implications for mentor recruitment and training. The fact that mentoring can be provided by volunteer mentors makes it an attractive, potentially cost-effective means of supporting carers. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Caregiving Carer Intervention Mentoring Mixed methods Social support

* Corresponding author at: Faculty of Health, Social Care and Education, St George’s University of London and Kingston University, 2nd Floor Grosvenor Wing, Cranmer Terrace, Tooting, London SW17 0RE, UK. Tel.: +44 20 8725 4756. E-mail address: [email protected] (N. Greenwood). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.06.011

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What is already known about the topic?  As populations age worldwide and people live longer with long-term conditions, the number of informal carers is increasing.  Being a carer frequently requires support and carer mentoring services are one form of such support.  However, despite their popularity, little is known about how mentoring schemes works or the impact it has on carers or carers’ experiences with such services. What this paper adds  The unique nature of the mentor-carer relationship with non-judgemental listening and confidential sessions, falls somewhere between formal and informal support and offers a highly valued intervention.  Adopting mixed methods has taken our understanding of the impact and experiences of carer mentoring further.  The qualitative findings suggest that carers receiving support from volunteer mentors perceive many benefits including emotional support and gaining new perspectives on caring.  The quantitative findings show that receiving mentoring is associated with improvements in carer wellbeing and confidence in caring. 1. Background Worldwide, the numbers of informal or unpaid, frequently family carers are expected to increase as populations age and severely disabled people live longer. Carers, or caregivers as they are also known, play a vital role supporting older people and people with disabilities. For example, in the UK it has been estimated that they save the economy £119 billion annually, considerably more than the cost of the National Health Service (Carers, UK, 2011). The satisfactions associated with being an informal, often family, carer are increasingly being identified (Kramer, 1997; Mackenzie and Greenwood, 2012), but caring is also known to be associated with adverse consequences for carers. Amongst carers of people with long-term conditions such as dementia and stroke, identified unfavourable outcomes include poor physical and emotional health, financial strain, burden, stress, social isolation and reduced quality of life (Beeson, 2003; Drentea et al., 2006; Ekwall et al., 2003; Greenwood et al., 2008; Hirst, 2004). Carers’ support needs have been highlighted in national strategies for dementia due to the stressful nature of caring for someone with dementia (Department of Health, 2009; NSW Department of Health, 2006; The Scottish Government, 2010). Awareness of the difficulties faced by carers has led to the development of a variety of psychosocial interventions aimed at supporting carers. These include group and individual counselling, educational programmes and problem-solving training. Overall the evidence for the effectiveness of these interventions is mixed and the quality of the research has been questioned (e.g. amongst carers of stroke survivors: Visser-Meilly et al., 2005; Brereton et al., 2007). Much of the research has centred on carers of people with dementia.

Focussing on interventions for this group, Burgio (2001) concluded that comprehensive, intensive and individually tailored support is more likely to be effective than group support. Similarly, Etters et al. (2008) reported that individual, multi-component interventions can decrease carer burden and improve carer quality of life. Such interventions can also delay institutionalisation of the person being cared for. 1.1. Mentoring Various interventions aimed at improving social isolation by increasing social support for carers have been developed. Social support has been described as ‘. . . the provision of informal help in order to try and meet someone’s psychological needs. . . it consists structurally of informational, practical and emotional assistance. . . and companionship.’ (Milne, 1999, p. 4 cited in Charlesworth et al., 2009). This fits well with descriptions of mentoring. Definitions of mentoring vary and can overlap with other interventions such as befriending. However, a typical description is that it is a means of reducing social isolation where a mentor, often someone with direct personal experience of the situation or condition, provides responsive, variable support tailored to individual mentee’s needs (Dickens et al., 2011a). Mentors are usually volunteers and often themselves former carers. They can offer empathy and understanding helping mentees adjust to caring (Sherman et al., 2004). In the UK the numbers of mentoring services are expected to grow with policy changes. For example, the UK National Dementia Strategy (Department of Health, 2009) put the development of peer support networks for carers as a high priority and promised to support the development of these schemes. Furthermore, volunteering is increasingly recognised as being beneficial for the volunteers themselves. The many positive effects identified include physical health benefits (Petriwskyj and Warburton, 2007; Casiday et al., 2008) and reduced mortality (Lum and Lightfoot, 2005) particularly in older volunteers (Harris and Thoreson, 2005; Warburton, 2006). These findings make the development of volunteer provided mentoring schemes even more important. However, despite their growing popularity, exactly how mentoring and other peer support interventions work, and the benefits they may offer remain uncertain (Sabir et al., 2003). Based primarily on quantitative methods, the available evidence for the benefits of mentoring is inconsistent. Some studies report positive findings, for example, carer mentees report improved knowledge of resources (Veith et al., 2006) and improved emotional states (Mead et al., 2010). In contrast, other studies have identified little effect on carer wellbeing. Research here includes studies by Charlesworth (2008) and Dickens et al. (2011a) who found no evidence that mentoring had a beneficial impact on health status, social activity or depression. Similarly Pillemer and Suitor (2002) tested a peer support intervention aimed at social support enhancement for carers of relatives with Alzheimer’s disease and found no significant impact.

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Carer mentoring services are seldom based upon psychological theories. This is of concern since without a theoretical basis, selection of appropriate outcomes and understanding of those likely to benefit from an intervention will be difficult. Furthermore, there is evidence that interventions aimed at reducing social isolation in older people are more likely to have a positive effect on the recipients if they have a theoretical basis (Dickens et al., 2011b). There are also a number of issues with the research here which may reduce the likelihood of identifying a significant impact. Firstly, studies tend not to take into account the dynamic nature of caring. Many carers support people with long-term conditions on a downward trajectory (e.g. dementia) and as a result, caring may become increasingly difficult over time with an associated negative impact on carers. Therefore, showing statistically significant improvement in outcomes may not be a reasonable expectation. Indeed, little or no change in outcomes might be deemed positive. Secondly, these studies tend to rely solely on quantitative methods where average changes are reported and will not identify individual differences where some carers may benefit more than others. Furthermore, using structured questionnaires will not necessarily measure changes in outcomes of importance for individual carers. For a variety of reasons, mixed methods are increasingly being adopted in health services research (Tashakkori and Teddlie, 2003). These include facilitating investigation of complex phenomena and giving more insight than would be gained by one approach alone (Cresswell, 2009). Using two methods means that each method can counterbalance the weaknesses of the other whilst taking advantage of the strengths of both (Cresswell, 2009). Compared to one method alone, mixed methods can also produce both a richer picture (Thurmond, 2001) and a coherent whole (Johnson and Onwuegbuzie, 2004). This approach can also be very useful in exploratory research (Teddlie and Tashakkori, 2009). Given the limitations of quantitative research alone, additional evidence combining qualitative and quantitative methods is one way forward. Qualitative investigation can give insight into carers’ experiences of mentoring and improve understanding of the impact on carers from their perspective, thus complementing the quantitative evidence. 1.2. Background to the mentoring service The mentoring service investigated in this study was run by a local voluntary sector organisation in London, England. The service’s stated aims include emotional and practical support for carers, increasing carer confidence or self-efficacy in caring, advice to help carers access services and information provision. The service is also described as offering a ‘listening ear’ to carers. The volunteer mentors provide one-to-one support usually visiting mentee carers weekly in their own homes on approximately a weekly basis. Mentoring is offered for a period of between six to 12 visits for current carers and is reviewed at the fourth session. At this time, the mentor talks with the carer to

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determine whether they would prefer six sessions or whether they feel they would benefit from receiving additional visits up to a maximum of twelve. Former carers, where the cared for person has died, are always offered 24 sessions with a review of the service at the tenth session to see if they would prefer to stop receiving the service at the twelfth visit. Mentors are recruited locally and receive training both before and during their role. Initial training includes an introduction to mentoring, listening skills, safeguarding for adults and children and bereavement training. Ongoing training includes suicide awareness and understanding dementia. Volunteers also have monthly supervision from the service manager, a qualified counsellor and former nurse. At the time of the study, the service had been in operation for five years and the majority of the mentors, but not all, were former carers. 2. Methods Given how little is known about carer mentoring, a mixed methods approach featuring a combination of qualitative and quantitative methods was deemed the best way in which to explore the primary research questions which were:  Does mentoring have a significant positive effect on the wellbeing of carer mentees in terms of mental health, quality of life and confidence in caring? (Quantitative scales)  How do carers experience and perceive the process and benefits of mentoring? (Qualitative interviews) This combined approach was also adopted to make it possible to explore the final question:  What mechanisms can be proposed to understand how mentoring may work? (Integration of quantitative and qualitative findings) Applying Creswell’s (2009) categories of mixed methods research, the approach in the present study can be described as concurrent triangulation. Here qualitative and quantitative methods are weighted equally and used simultaneously. Data are analysed separately and the findings then integrated. A strength of this approach is that it makes it possible to identify both convergence and complementarity (Greene et al., 1989). 2.1. Quantitative: the self-completion questionnaire The questionnaire included demographic information such as carer gender and age and also specific outcome measures relating to the service’s aims of improving carer emotional wellbeing, quality of life and confidence in caring. Carers are often under considerable strain making it essential that the questionnaire was neither too long nor too arduous to complete. To achieve this, the research team consulted the mentors on the selection of outcome measures.

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2.2. Emotional health

2.5. Piloting

The Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983) is a frequently used, selfcompletion, 14-item scale with seven questions about anxiety and seven about depression covering the preceding week. It has been used widely used outside the hospital setting (McDowell, 2006) and was therefore deemed a suitable tool. It is also commonly used in research with carers (e.g. Greenwood et al., 2008). Anxiety and depression are scored separately and range from 0 to 21 for each dimension with higher scores indicating greater distress. The scale has well-established validity (Bjelland et al., 2002) and reliability and is sensitive to changes (Herrmann, 1997). A cut-off of eight to identify possible ‘cases’ of anxiety and depression (Bjelland et al., 2002) has been applied. When the mentors were consulted, they thought the scale’s name might confuse carers. Therefore, in the final questionnaire the HADS came under the general title of ‘Wellbeing’.

The entire questionnaire was piloted on a group made up of five carers and mentors. They reported that it was acceptable both overall and in terms of its length and ease of completion.

2.3. Quality of life Although quality of life is frequently used as an outcome in health and social care, it ‘is a multi-level and amorphous concept’ which ‘. . . poses inevitable challenges for measurement’ (Bowling et al., 2002, p. 354). There remains no overall agreement on how it should be defined which has led to a plethora of measurement tools of varying length and complexity. de Boer et al. (2004) demonstrated that a single visual analogue scale ranging from 0 to 100 (where 0 is the poorest and 100 is the best possible quality of life) compares well with longer instruments with several questions. In the interests of making the questionnaire short and easy to complete, the de Boer et al. (2004) scale was adopted. 2.4. Carer confidence or self-efficacy Mentors were unhappy with the term ‘self-efficacy’ and the term confidence was therefore used. There is considerable overlap in the concepts of self-efficacy and confidence. Indeed, self-efficacy scales generally ask participants to rate the strength of their belief in their ability to complete a variety of tasks, usually expressed as saying how confident they are in performing the task. Concern has been voiced that measuring self-efficacy using a ‘one size fits all’ approach ‘usually has limited explanatory and predictive value because most of the items in an all-purpose test may have little or no relevance to the domain of functioning.’ (Bandura, 2006, p. 307). Therefore, it was decided to construct a scale assessing carer confidence specifically for the study which covered the explicit aims of the service. This was developed in conjunction with the mentors. Carers were asked to rate their confidence on a series of statements using a scale from 0 (Not at all confident) to 10 (Very confident). For example: How confident are you that you can . . . ‘Set aside time for yourself’?

2.6. Quantitative data analysis Data were subjected to both descriptive and inferential statistics (the level of significance was set at p  0.05). Scale data were ordinal therefore non-parametric tests were used to determine whether changes before and after mentoring were statistically significant. The Wilcoxon signed rank test was used to identify mean changes in anxiety, depression, quality of life and carer confidence. Chi squared was used to investigate changes in the number of cases of anxiety and of depression. 2.6.1. Participant recruitment During the study period, as soon as carers were assigned a mentor but prior to starting mentoring, the service manager asked all carers if they would complete the structured self-completion questionnaire. The study was explained to them and they were provided with information about the project. It was stressed that they were under no obligation to take part and confidentiality and anonymity were assured. Carers were provided with an envelope for completed questionnaires which they sealed and returned to the research team. Participant consent was assumed if carers completed and returned the questionnaires. On completion of mentoring, the same process was followed. 2.7. Qualitative: the interviews Open-ended interviews were selected as little is known about how mentoring is perceived and this method allows exploration of the experiences of mentoring in participants’ own words (Bowling, 2002). Interviews were carried out by a researcher experienced in interviewing carers, and a topic guide was used to ensure that relevant areas of interest, such as perceived benefits of mentoring and important characteristics of mentors, were covered. Given the diverse and often difficult nature of their caring responsibilities, carers were given the option of face-toface or telephone interviews. Interviews were digitally recorded and transcribed. 2.7.1. Participant recruitment After completing mentoring, participants were purposively sampled from those that had completed the questionnaires so that a range of carers were invited for interview in terms of age group, ethnicity and gender. The manager contacted selected carers to ask if they would be interested in participating and explained that the interview was to learn about carers’ experiences of mentoring. It was stressed that they were under no obligation to take part, that all data would be anonymised and would remain confidential and that only the research team would have access to their interviews. If carers were interested in

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participating, a researcher telephoned them to confirm whether they still wanted to take part. Carers were reminded that they could terminate the interview at any time without providing an explanation. If they were still happy to be interviewed, a time and place convenient to the carer was arranged. If a face-to-face interview was not convenient, a telephone interview was offered. Before face-to-face interviews began, participants were given a study information sheet. If they were still happy to proceed, they then signed a consent form. For telephone interviews, the study information was read out by the researcher and participants gave verbal consent. 2.8. Qualitative data analysis Qualitative data analysis was an ongoing process starting early in data collection. Interview transcripts were analysed using conventional content analysis (Hsieh and Shannon, 2005). The two authors independently immersed themselves in the data, reading and re-reading a sample of transcripts. Coding of the data started with creating categories. This open coding is intended to describe all aspects of the interviews’ content. The authors then met to discuss which categories should go together and how each group should be named. These larger categories made up the themes described below. This process continued until the researchers reached consensus and the data could be reduced no further, ensuring that the data were described and summarised (Elo and Kynga¨s, 2008). All remaining transcripts were then analysed using these categories. Following the guidance of Mays and Pope (2000), the researchers attempted to identify any negative or ‘deviant’ cases amongst participants in terms of their experiences in mentoring. Identification of deviant cases can help refine the analysis and also facilitate explanation of the majority of cases. Analysis also aimed to identify any patterns or relationships in the themes, for example any themes associated with participant age groups. Data collection continued until no new themes were identified in the interviews. 2.9. Ethics approval The study was approved by the Faculty Research Ethics Committee in the Faculty of Health and Social Care Sciences at Kingston University and St George’s University of London. 2.10. Findings 2.10.1. Participant demographic characteristics During the study period, twenty-five carers completed the questionnaire both before and after receiving mentoring. The majority were female (88%), all were aged over 30 years and most were caring for males (68%). White participants (including White British, White European and White Irish) dominated the sample (76%). Nearly half (48%) were spouses and a third (36%) were parents. Most (80%) carers were living with their cared for. The ethnicities of those being cared for were very similar to the carers with nearly seven in ten (68%) belonging to the

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same ethnic groups. The cared for varied considerably in age – close to a third (36%) were under 30 years old whilst a similar proportion (32%) was over 80 years. They had a wide range of diagnoses and over a quarter (28%) had multiple conditions. Fifteen out of seventeen carers approached agreed to be interviewed but only 11 participated because four were not contactable during data collection. Table 1 shows that these carers and their cared for were generally representative of the group as a whole, although no male carers were interviewed. 2.10.2. Anxiety and depression (HADS) Prior to mentoring, overall average anxiety scores were higher (12.96; SD = 3.31; range 7–19) than depression scores (10.60; SD = 2.71; range 4–15). After mentoring both anxiety and depression scores were significantly reduced (p < 0.001 for both) suggesting a positive impact of mentoring on carer emotional health (Table 2). An alternative way of looking at changes in emotional health is to compare numbers of cases of anxiety and depression before and after mentoring. Table 3 shows the reduction in cases of anxiety from 23 to 13 and for depression from 21 to 9. This reduction is also statistically significant (anxiety p = 0.006; depression p = 0.002) strengthening the evidence for a positive impact of mentoring on carer emotional health. 2.11. Quality of life Positive changes in perceived quality of life were also statistically significant (p = 0.02) with ratings increasing for two-thirds of carers (Table 4). 2.12. Carer confidence Carers were asked to rate their confidence (0 = Least confident to 10 = Most confident) on a number of tasks related to caring. Comparing carers’ ratings before and after receiving mentoring shows average confidence ratings increased on every item (Table 5). This improvement was statistically significant (p < 0.05) on all dimensions except confidence in asking the General Practitioner (GP) for help. 2.13. Themes identified from qualitative interviews Nine carers were interviewed face-to-face and two over the telephone. Interviews lasted on average 30– 45 min. Participants were generally very positive about mentoring and no clear patterns in relation to carer demographic characteristics and themes were identified. Two participants appeared less positive than others about mentoring. However, for both participants their interviews suggested this was because their experience did not match their expectations, rather than relating to their demographic characteristics or caring situations. The following themes were identified from the interviews. Quotes are provided to illustrate themes.

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Table 1 Demographic characteristics of carers and their cared for. Questionnaire participants

Interview participants

Carer (n = 25)

Cared for (n = 25)

Carer (n = 11)

Cared for (n = 11)

Gender Female Male

22 (88%) 3 (12%)

8 (32%) 17 (68%)

11 (100%) 0

2 (18%) 9 (82%)

Age <30 31–50 51–70 71+

0 9 (36%) 5 (20%) 11 (44%)

9 1 2 13

(36%) (4%) (8%) (52%)

0 3 (27%) 2 (18%) 6 (55%)

3 (27) 0 1 (9%) 7 (64%)

Ethnicity White (British/Irish/European) Black (British/Caribbean) Other including Asian (British) Missing

19 (76%) 2 (8%) 4 (16%) 0

17 1 6 1

(68%) (4%) (24%) (4%)

10 (90.9%) 1 (9.1%) 0 0

8 (73%) 0 2 (18%) 1 (9.1%)

Carers’ relationship to cared for Spouse/partner Parent/grandparent Adult child

12 (48%) 10 (40%) 3 (12%)

7 (63.6%) 3 (27.3%) 1 (9.1%)

Length caring Less than 5 years More than 5 years Missing

7 (28%) 18 (72%) 0

2 (18%) 8 (63%) 1 (9%)

Mean anxiety score prior to mentoring (range), Max = 21 Mean depression score prior to mentoring (range), Max = 21 Mean quality of life rating prior to mentoring (range), Max = 100

12.96 (7–19) 10.6 (4–15) 49.17 (15–85)

11.3 (7–14) 10.2 (6–13) 53.3 (40–70)

Table 2 Changes in anxiety and depression before (T1) and after (T2) mentoring. n = 25

T1

T2

Statistical significance (Wilcoxon signed rank test)

Anxiety (maximum = 21) Mean Range

12.96 7–19

9.16 2–17

p < 0.001

Depression (maximum = 21) Mean Range

10.6 4–15

6.81 1–14

p < 0.001

Table 3 Changes in number of cases of anxiety and depression before (T1) and after mentoring (T2). n = 25

T1

T2

Statistical significance Chi squared test

Cases of anxiety Not anxious Anxious

2 (8%) 23 (92%)

10 (40%) 15 (60%)

x2(1) = 7.02, p = 0.008

Cases of depression Not depressed Depressed

3 (12%) 22 (88%)

15 (60%) 10 (40%)

x2(1) = 12.5, p = 0.0004

2.13.1. Being a carer Although not directly asked about this, carer participants described the impact of being a carer often mentioning isolation, depression and exhaustion. These themes are important because they suggest how mentoring may benefit them. Caring was recognised as difficult and often new.

‘I’d never done anything like this before, being a carer, and um, it came pretty hard when it . . . yes. It came pretty hard.’ Carer I (adult daughter) Social isolation resulting from reduced opportunities to go out and continue with pre-caring activities and the decline in visitors affected many carers.

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Table 4 Carers’ perceived quality of life before mentoring (T1) and after mentoring (T2) highlighting those carers that had changed. n = 24

Mean T1

Mean T2

Wilcoxon signed rank test

Nos. of carers making positive changes

Nos. of carers unchanged

49.17

55.13

p = 0.02

16 (66.7%)

2 (8.3%)

Table 5 Confidence ratings before starting (T1) and after completing mentoring (T2). Statement

Mean T1

Mean T2

Statistical significance (Wilcoxon signed rank test)

Set aside time for self (n = 25) Know where to get information about benefits and services (n = 25) Know where to go for advice (n = 24) Ask for help or support from services if you need it (n = 25) Ask for help from your GP when necessary (n = 25) Would ask for respite if you thought you needed it (n = 22) Keep things in perspective (n = 22) Could at least sometimes identify satisfying aspects of being a carer (n = 25) That you are doing. . . the best possible job of being a carer in the circumstances (n = 20)

2.60 4.72 4.46 3.68 5.4 2.95 4.05 4.84

4.72 6.28 6.63 5.80 6.16 4.82 6.05 6.04

p = 0.001 p = 0.007 p = 0.003 p = 0.001 p = 0.12 (ns) p = 0.005 p = 0.003 p = 0.012

5.50

7.05

p = 0.013

(0 = not at all confident, 10 = very confident). Question: For each of the following questions please circle a number on the scale to show how confident you are about each one where: 0 = Not at all confident and 10 = Very confident.

‘I see my family, but friends, I don’t know. . . it’s alright to start with and then they gradually disappear, you know. So I don’t really see anyone much.’ Carer J (spouse) Several described themselves as depressed prior to mentoring. ‘I find that if I’ve got very tired, I’ll land up in the day then shouting at him. And then I feel terrible. And it’s only because I’m tired and I’d got very low again, I was going a bit into depression and kept crying and everything was really on top of me.’ Carer A (spouse) ‘It was quite difficult, I think I was quite depressed as well, you know when you look back at it. But you know, I came out the other side of it with help.’ Carer E (parent) Needing information and experiencing difficulties in accessing services and information were also highlighted. ‘I’d been trying to find out so many different things, and going to so many places that I got quite confused.’ Carer I (adult child) 2.13.2. Characteristics of a good mentor Carers suggested a long list of desirable personality traits for mentors. These included: patience, understanding, warmth, enthusiasm, being approachable, friendly, open-minded and caring. Carers generally agreed that mentors needed to be good listeners and easy to talk to so that they could connect with mentees. ‘You must have rapport and feel you can talk freely.’ Carer C (spouse) Mentors’ motivation, enthusiasm and enjoyment were also identified as important ingredients of mentoring. The fact that mentors had chosen the role, and were unpaid was assumed to mean mentors believed in mentoring and really wanted to be in the role.

‘When it’s done voluntary you’re doing it because you want to do it. If it’s somebody who’s being paid to do something, quite often they’ll do it but it’s a job.’ Carer A (spouse) The majority of mentors had themselves been carers at some point. This experience was regarded as paramount for some carers, whilst others considered it less important as long as mentors had relevant personal characteristics. Those who thought caring experience was important often said it was easier to talk to someone who knew what they were going through. Hearing about the mentor’s experiences also helped them. ‘I think that was one of the main advantages of the system, is that you’re speaking to someone that has been through what you are now going through. And that gives you a lot of confidence in them.’ Carer K (spouse) Not all carers were aware of whether or not their mentor had been a carer and did not regard it as very important. However, these carers still emphasised that mentors should have relevant mentoring experience or background knowledge. ‘I think what’s more important is, you know, life experience really. . . she understands what it’s like to be a parent. You know whereas somebody who probably hadn’t had a child, probably wouldn’t understand as much.’ Carer G (parent) When asked about what was important when pairing carers with mentors, carers often found it difficult to describe what was key except that they should ‘get on’. Most did not think that matching on demographic details such as age was important, although some carers suggested they might have been uncomfortable talking to a male mentor. Similarity in personality, sense of humour and interests were most commonly cited as possible matching criteria.

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2.13.3. The mentoring process and benefits Carers described many aspects of mentoring that they found beneficial. These included very specific activities undertaken by the mentors but also related to more general aspects of mentoring sessions. 2.13.3.1. Reducing isolation and providing contact with the outside world. Early in their interviews carers often mentioned how few people they saw on a day-to-day basis, often saying this had worsened over time. Mentor’s visits helped reduce this social isolation and loneliness by helping them feel ‘more part of things again.’ ‘. . . just to speak to somebody for an hour, it made so much difference. Unless you’ve been in the position, you really can’t imagine how all of a sudden, oh hell, you’re a pariah, nobody wants to know you. You’re just stuck out on a limb. And it did, it really did help a lot.’ Carer A (spouse) ‘As I said I don’t see many people so when you see someone and you’ve been talking to them, your mind’s, your mind feels better in itself.’ Carer J (spouse) Mentoring also meant carers felt less alone. ‘. . . that there’s somebody on your side as it were. So that, yes, you do feel less abandoned as it were. And that helps.’ Carer B (spouse) 2.13.3.2. Relationship with mentors and the mentors’ role. The understanding that mentors would not judge them, and that whatever they said during mentoring was in confidence, was highly valued. Mentors were thought to really understand carers, their situations and emotions and in this respect were often compared favourably with families and professionals. One carer described this benefit as ‘not having to put a face on’ for the mentor. Some carers appeared to view mentoring primarily as an opportunity to talk openly and informally to someone outside their normal circle. Occasionally it was seen as a chance to focus, albeit briefly, on life outside of caring by allowing them to talk about things other than caring. The feeling they could ‘talk about anything’ was highly valued. ‘It’s not just talking about illness and that all the time. I mean I take my husband to the stroke club and there’s a lot of people down there, but their topic of conversation is more or less ‘I take more pills than you do’.’ Carer A (spouse) ‘Well, if I could think of anything I wanted to ask her, I would, and then I could just chat to her.’ Carer I (adult daughter) 2.13.3.3. Emotional support and release. Mentors often provided emotional support allowing carers to disclose feelings or experiences they would not reveal to others who do not understand the difficulties of being a carer. It gave them an opportunity to describe experiences and emotions that they may be unwilling to reveal to others. Talking in this way allowed carers to unburden themselves, leading to a sense of emotional release.

‘Because I was sort of bottling everything up as well. So yeah, it was quite nice. To kind of get it off your shoulders without a friend sort of listening or making an opinion or whatever.’ Carer H (parent) ‘[My cared for] did some awful things to me that I would never tell other people. . . but I would tell her that, but I’d be a bit embarrassed to tell my friends.’ Carer E (parent) 2.13.3.4. Enjoyment. Mentoring was viewed as generally enjoyable and anticipated with pleasure. The vast majority of carers said they enjoyed the mentors’ visits and sessions were described as ‘interesting’. This was partly because mentors were often seen as very pleasant, friendly and as good listeners. ‘Because I can’t have a conversation with my beloved as I call him, and very little conversation with the girls. It’s all just rush, rush, rush, rush. It’s a very busy life, and um, I don’t often get this chance and sit down and talk. So no. . . It was calming.’ Carer F (spouse) One carer highlighted the outgoing, positive, upbeat nature of her mentor saying she valued mentoring because she now felt able to laugh again. ‘She . . . would let me tell her what I wanted to tell her, but you know, she sort of, she got me laughing again.’ Carer K (spouse) 2.13.3.5. Provision of advice and information. Other carers, but not all, highlighted the value they perceived in the advice and suggestions mentors provided. It was not uncommon for carers to accept mentoring because they saw it as a way of accessing information. Participants mentioned signposting and provision of information about benefits and services. ‘Also like she was saying about different helps you can get, well because he’s had it so long I’d already gone through all of that stage. But at the beginning, nobody tells you, they don’t tell you that you’re entitled to any money or any assistance.’ Carer A (spouse) 2.13.3.6. Helping carers cope: gaining a new perspective and problem solving. Carers also felt that mentors helped them feel more positive and able to cope with their situation. They said that mentors sometimes validated what they were already doing and reassured them that they were doing a ‘good job’. Mentors also reminded carers of the centrality of their role and their importance and value. This was often appreciated by carers. ‘[It was] very useful, because it put your life into perspective. Because you have no idea after all, you sort of grow into being a carer, it just happens over years and years and it’s only since my husband has been in hospital I’ve realised I was coping with a form of dementia.’ Carer D (spouse) Carers commonly described themselves as more confident, empowered and calmer because of mentoring.

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Table 6 Possible mechanisms and enablers in mentoring leading to reduced anxiety and depression, increased quality of life and confidence in caring. Being a carer (qualitative evidence)

Enablers – mentor characteristics

Possible mechanisms of mentoring

Outcomes (quantitative evidence)

Reduced emotional wellbeing Social isolation

Personality characteristics e.g. patience, warmth and approachability Good listener Non-judgemental Easy to talk to Good understanding of what it is like to be a carer (often a former carer) and/or knowledge of the cared for’s condition Can be spoken to in confidence Outside the carers’ usual circle Neither a friend nor a professional

Unburden self Emotional support and release Reducing isolation Contact with outside world Enjoyment Reassurance that ‘doing a good job’ Advice and information on services and benefits Problem solving Mentor provides different perspectives enabling new carer perspectives

Reduced anxiety and depression Improved quality of life

Difficulties coping Difficulties accessing services

‘So the fact that the mentor showed me how to perhaps manage my time more, so that I did have some ‘me’ time, and I can now leave him for half an hour, or an hour, and that, he’s happier with that.’ Carer K (spouse) In addition to more practical advice, mentors also helped by allowing carers to see things differently and to take the time to think through suggestions and options. Mentors were seen to help with time management and ‘sorting things out’ partly because of their objective, unbiased perspective. Some carers also emphasised that the fact that mentors were ‘complete strangers’ whom they have never met before was important. ‘She did help me . . . see a different point of view. And mentoring is to see a different point of view. Another person’s point of view, and you try to relate it to yourself.’ Carer C (spouse) ‘It was really, actually very simple strategies, but when you’re in the midst of it all you can’t think straight really, and she sort of got me back on the right road, and . . . to think what’s important and what isn’t important, you know.’ Carer E (parent) The fact that mentors were outside their normal relationships with families and friends was valued. ‘. . . she brings a different point of view. Because she doesn’t know your friends and she doesn’t know your family or anybody else. So she’s just listening to what you’re saying, and making the decisions basically from what you’re saying to her, not anybody else’s opinion is coming through. . .’ Carer H (parent) Carers also sometimes said that being able to talk to the mentor about specific difficulties they had been experiencing within their families was valuable because the mentor had suggested impartial, alternative ways of looking at the situation. 2.14. Integration of the quantitative and qualitative findings This section integrates the qualitative and the quantitative findings and suggests some possible mechanisms by which mentoring may benefit carers. Table 6 summarises and combines the main findings and provides potential means by which mentoring may benefit carers.

Increased confidence in caring

In summary, carers may struggle to cope and become socially isolated. The process of mentoring provided by mentors with the right personal characteristics, training and experiences (enabling factors), benefits carers in a variety ways. These include offering opportunities to talk to someone outside their normal circle who can provide useful information and impartial advice, and also help them develop new, more positive perspectives. Through these mechanisms mentoring may lead to reductions in anxiety and depression, improve carers’ quality of life, increase their confidence in caring and strengthen their ability to cope. This description is clearly tentative and will require more research if it is to be developed. However, it offers a means to investigate the processes and enablers involved in mentoring. 3. Discussion This exploratory study increases our understanding of mentoring further. Unlike earlier research, we used mixed methods which allowed us to quantitatively measure changes in carer wellbeing and also to identify the benefits of mentoring from their perspective. Combining these methods made it possible to suggest mechanisms by which these changes may occur. A flexible approach to interviewing meant that two of the eleven qualitative interviews took place over the telephone. This allowed us to capture the experiences of carers who were unable to meet the interviewer face-to-face. Concerns have been raised that telephone interviews produce less in-depth responses than face-to-face interviews. However, like authors such as Sturges and Hanrahan (2004) we found that although responses were slightly shorter on average than the faceto-face interviews, similar themes were identified using the two methods. The study also suggested that the nature of the mentorcarer relationship, falls somewhere between formal and informal support. The non-judgemental listening and confidential sessions offer a unique, highly valued intervention. Carers also believed that their mentors’ personal characteristics facilitated the mentoring process. Mentors’ own experience as carers was frequently, but not always, seen as an important aspect of the mentor-carer relationship, perhaps by enhancing mentors’ empathy and understanding (Sherman et al., 2004). Goffman (1963) referred

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to ‘similar others’ who could provide the individual with ‘instruction in the tricks of the trade and with a circle of lament to which he can withdraw for moral support and for the comfort of feeling at home, at ease, accepted as a person who really is like any other normal person.’ (Goffman, 1963, p. 32). This comes close to how some carers here described the benefits of mentoring. Mentoring, in this case, can be viewed as a mixture of social and emotional support provided by a non-judgemental outsider, thus allowing carers to describe, in confidence, their often negative experiences and feelings. Mentoring may reduce carer distress and allow them to become more confident in their role which in turn may improve the quality of their lives. Some, but not all, previous studies have identified a positive impact of mentoring on carers (Pillemer and Suitor, 2002; Veith et al., 2006; Charlesworth, 2008; Mead et al., 2010; Dickens et al., 2011a). Adopting mixed methods here made it possible to measure ‘overlapping but also different facets of a phenomenon, yielding an enriched, elaborated understanding of that phenomenon’ (Greene et al., 1989, p. 258). This approach made it possible to investigate the carers’ perspective and to develop the findings further by suggesting possible mechanisms by which mentoring may work. Improved understanding of the mentoring process is useful in terms of suggesting ways of enhancing mentor selection and training to maximise its benefits. The fidelity to the mentoring process provided in the mentor training is hard to guarantee. Although the volunteer mentors are selected and trained both before and during their mentoring role, it is important to recognise that training is relatively short and it is unclear how closely mentors adhere to the model of mentoring provided in training. However, this may well be true for many such interventions. In addition, it was apparent from carers’ perspectives, that there was a range of approaches and diverse elements in mentoring which varied with individual mentor-carer relationships. Arguably, this may also be a strength of the approach as it allows great flexibility and tailoring to individual mentor-carer pairs in terms of the carers’ situations and needs and the skills and experiences of mentors. As with many mentoring schemes, volunteer mentors here were mostly former carers and evidence suggests that they may benefit from their role. The experiences of former carers are seldom highlighted in the literature but it is known that many former carers experience negative emotions and loss of self esteem and purpose once their caring role ends (Jenkinson, 2004). They may also find themselves poorly equipped for life after caring due to the long-term social, psychological and health consequences of caring. Returning to employment may also be difficult because of loss of skills during their time caring (McLaughlin and Ritchie, 1994). It is known from other research that being a volunteer is recognised as having beneficial effects, such as increasing longevity and improving physical and mental health in older people (Lum and Lightfoot, 2005). In addition, the skills developed here as a mentor may be useful in employment. Further research to investigate specifically the potential benefits for these volunteer mentors would therefore be valuable.

Carers frequently appear to lose sight of their own importance and value. Our findings highlighted that many carers receiving the mentoring service felt that mentors validated what they were doing and gave them reassurance that they were doing a ‘good job’. This was very much appreciated by carers and should perhaps be emphasised in mentor training. Some carers highlighted the fact that mentors were unpaid volunteers who had chosen to take on the role. This was thought to suggest that they really believed in the value of mentoring and were committed to the role. It was also clear that some carers really appreciated that the volunteers had their own caring experiences as this was thought to give them insight into the challenges of being a carer. It also allowed volunteers to share how they had managed their situation. We have been unable to identify evidence to suggest whether being a volunteer with caring experience influences the impact or perceptions of mentoring making this an area worthy of investigation. 4. Limitations This study investigated the impact of one mentoring service for carers with a relatively small sample size over a short period of time. For this reason it is not possible to draw any conclusions about the long-term impact of mentoring and long-term follow-up would be valuable. We also had a relatively small sample but the fact that there were statistically significant changes in carer wellbeing suggests that at least in the short-term, mentoring can benefit carers. Additional research with a larger sample size may help identify who benefits most and least from mentoring. Furthermore although some males and carers from minority ethnic groups agreed to be interviewed, in fact it was only possible to interview women and one person from a minority ethnic group. Again, a larger sample may have avoided this. Investigation of the mentors’ perspectives would have enhanced our understanding of mentoring process and may have made it possible to identify any benefits for them. 5. Conclusions As populations age worldwide, it is important to identify cost-effective means of supporting carers. Mentoring provided by volunteers from the voluntary sector would appear to be a useful means of offering support that complements informal and statutory support. We have suggested possible mechanisms for how mentoring might benefit carers but more research would help clarify these and could make an important contribution to mentor selection and training. Acknowledgments The authors would like to thank the South West London Academic Health and Social Care System who funded the study; Sue Barrett (Volunteer Services Manager, South Thames Crossroads); the carer participants and Professors Vari Drennan and Ann Mackenzie for their support with the research.

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